Nyeri merupakan suatu respon tubuh terhadap suatu penyakit maupun suatu tindakan medis. Nyeri yang tidak terkontrol dapat menurunkan kualitas hidup dari pasien.  Dokumentasi nyeri merupakan salah bagian penting dalam keperawatan. Melalui dokumentasi dapat tercipta komunikasi yang baik antara tenaga kesehatan, sehingga tercipta pelayananan kesehatan optimal bagi pasien khususnya dalam masalah nyeri. Untuk mendapatkan dokumentasi yang akurat maka dikembangkanlah sebuah program pencatatan nyeri berbasiskan data elektronik. Program ini memiliki fitur yang terintegrasi dari pengkajian, diagnose keperawatan, intervensi keperawatan, dan pengkajian ulang.

Kata Kunci : Nyeri, Dokumentasi elektronik, Pain Flowsheet Electronic Nursing Record

CEM. (2014). The Collage Emergency Medicine Best Practice Guideline Manajemen Pain in Adults. Diakses dari: http//: rcem.ac.uk

Goldstein, D. H., Phelan, R., Wilson, R., Ross-White, A., Vandenkerkhof, E. G., Penning, J. P., & Jaeger, M. (2013). Brief review: Adoption of electronic medical records to enhance acute pain management. Canadian Journal of Anaesthesia = Journal Canadien D’anesthesie, 164–179. http://doi.org/10.1007/s12630-013-0069-6

Gunawan Susanto, S. (2012). Sistem Informasi Rekam Medis Pada Rumah Sakit Umum Daerah ( Rsud ) Pacitan Berbasis Web Base. Speed – Sentra Penelitian Engineering Dan Edukasi, 9(3), 40–46.

Hing, E., & Hsiao, C.-J. (2010). Electronic medical record use by office-based physicians and their practices: United States, 2007. National Health Statistics Reports, (23), 1–11.

Lee, J. M., Kim, Y. A., Jung, H., & Song, M. (2012). Development of Pain flowsheet based on electronic nursing record system. Studies in Health Technology and Informatics, 180, 1065–1069. http://doi.org/10.3233/978-1-61499-101-4-1065

Mantas, J., Zikos, D., & Diomidous, M. (2013). Exploring the potential of an electronic documentation system to reduce length of stay. Studies in Health Technology and Informatics, 192(1-2), 1179. http://doi.org/10.3233/978-1-61499-289-9-1179

Park, H. A., Min, Y. H., Jeon, E., & Chung, E. (2012). Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System. Healthcare Informatics Research, 18(2), 136–144. http://doi.org/10.4258/hir.2012.18.2.136

Potter & Perry.(2010).Fundamental Of Nursing.Jakarta:Salemba Medika

Samuels, J. G. (2012). Abstracting pain management documentation from the electronic medical record: Comparison of three hospitals. Applied Nursing Research, 25(2), 89–94. http://doi.org/10.1016/j.apnr.2010.05.001

Samuels, J. G., & Kritter, D. (2011). Pain Management Documentation Analyzing One Hospital ’ s Computerized Clinical Records, 29(9), 512–518. http://doi.org/10.1097/NCN.0b013e31821a1582

Ward, Jennifer.(2012).Nurse's Role in Pain Management. Diakses dari: http//:NurseTogether.com

Zaslansky, R., Rothaug, J., Chapman, R. C., Backström, R., Brill, S., Engel, C., … Meissner, W. (2014). PAIN OUT: An international acute pain registry supporting clinicians in decision making and in quality improvement activities. Journal of Evaluation in Clinical Practice, 20(1), 1090–1098. http://doi.org/10.1111/jep.12205